Series Examines Prospect of Universal Healthcare Coverage in India

26 Jan 2011

Recently, the Lancet published a special issue on India’s progress toward universal health coverage. A comprehensive and aptly timed analysis of healthcare in the backdrop of rapid economic growth, the series provides valuable insights into the achievements and challenges in India in recent years.  Papers in the series cover a wide range of topics, including an overview of the health scenario, mortality and morbidity, maternal and child health, infectious and chronic diseases, and finally, infrastructure, human resources and healthcare financing. The overarching message is one of a dichotomy – strong economic growth but a failing health system.

Although India has seen moderate improvements in many health indicators over recent decades, the authors reveal a very bleak picture of the current situation – in short, the existing health system is severely inadequate in terms of outreach across subpopulations and geographic locations, and in various aspects of human health and diseases. With approximately 29% of the population living below the official poverty line, large out-of-pocket expenditures associated with private healthcare delivery often make the poor more vulnerable or simply push more people into poverty. After assessing the shortcomings of current institutions, the discussion concludes with a call for universal healthcare by year 2020. In this post, I will provide an overview of the entire series, examining each paper independently and also commingling subject matters to give a sense of the full picture.

The series is divided into two sections – comments and academic papers, with several contributory authors from diverse research, administrative and activist backgrounds. For this post, I will focus on the key messages from the research papers and leave the very engaging commentary for the reader to enjoy directly.

The first paper evaluates the effectiveness of infectious disease control in India. The authors note that although sweeping socioeconomic improvements have reduced the prevalence of infectious diseases over the past decades, about 30% of the total disease burden today is still due to the contagious ones. The Indian government follows a targeted approach in which individual prevention and cure programs are in place for a few major infectious diseases. Some of these programs, such as for HIV and leprosy, have been successful while programs aiming to prevent TB, malaria and the like are lagging behind. A second disease control component that is designed to detect and control outbreaks, administered by each state’s Department of Health Services, appears to be inefficient in providing timely updates and mobilizing resources.  In closing, the authors prescribe an overhaul of the infectious disease control mechanism through integrating independent prevention programs and improving disease surveillance through additional healthcare manpower at various administrative levels.

The second paper acknowledges India’s recent progress in reducing maternal and child mortality rates and malnutrition. However, the authors point out that the achievements are not enough to meet the national or Millennium Development Goals in a timely manner (e.g. the 2010 national target for infant mortality rate of less than 30 will not be achieved in rural areas even by year 2015). Secondly, although India boasts of a somewhat successful pre-school nutrition program (Anganwadi) and the largest school nutrition program (Mid-day Meals), early-life nutrition (for children less than 2 year old) is completely neglected by government programs. The authors identify several areas of enhanced intervention including a further strengthening of the National Rural Health Mission (NRHM 2005), conditional cash transfer programs for health and nutrition programs for younger children, decentralized planning, and investment in health research.

In 2004, some 11% of all deaths in India were attributable to injuries and 50% were due to chronic diseases such as diabetes, cancers and cardiovascular and respiratory diseases. The third paper of the series argues that the Indian population suffers from high-risk prevalence, and the burden of these diseases is only set to rise over the next decades (e.g. cancer deaths are estimated to rise to 1.5 million in 2030 from 730,000 in 2004).  The authors recognize that the availability of various cost-effective prevention methods has been overshadowed by inept public distribution and management systems, and that the private healthcare sector provides the bulk of these treatments and services at a high cost to the patron. Some progress has been made on tobacco control and the paper mentions a localized success story of diabetes prevention.  To conclude the discussion, the paper makes several short-term (2-year) and medium term (5-year) recommendations to the policymakers, ranging from the immediate implementation of a few low-cost interventions, to the integration of injury and chronic disease prevention with the national health mission, to long-term investments in healthcare research and information systems.

The fourth paper goes beyond the key message of the overall failure of healthcare system, as revealed by the previous papers, to examine disparities in coverage across regions and socioeconomic subpopulations. The main message is one of an undue burden of diseases, poor health outcomes and healthcare-related economic hardship on the less-privileged segment of the society. A few examples: while the 2004-05 national immunization rate was 44%, only 26% of the children of uneducated mothers were immunized; and the life expectancy in Madhya Pradesh, one of poorest states, is 56 years as compared to 74 in Kerala, the state with the best human development indicators. Significant inequity exists in terms of public healthcare expenditure too, with Himachal Pradesh spending almost seven times as much per capita as Bihar, for example. Finally, significant out-of-pocket expenditures associated with access to private healthcare services impoverish approximately 39 million Indians every year. The authors laud the establishment of the NRHM as the main instrument for the fight against inequity. Also notable are a few federal and state health insurance schemes aimed toward the financial risk protection of the poor. However, the authors emphasize the need for a knowledge-based approach – a mechanism that reinforces the current system with the use of health metrics and research, and policy decisions that are generated based on comprehensive information on a particular subpopulation or region.  

Availability of qualified health professionals across the country is the main ingredient for a successfully decentralized public healthcare delivery system. The fifth paper discusses a kind of double jeopardy when it comes to human resources for health in India – there is an acute shortage of trained health staff, and the workers are disproportionately absent from rural areas.  As an example, there are about 13.3 allopathic doctors per 10,000 people in urban India, while only 3.9 in rural areas (in comparison, USA had an average of 26.7 doctors per 10,000 people in 2004). There is also a significant variation among health workers in terms of the quality of training received and the adequacy of resources needed to perform their duties. The authors argue that a comprehensive national human resources policy is required, one which will produce more competent healthcare workers and in greater numbers, provide the right incentives for a decentralized deployment of this workforce, and assimilate alternative medicine practitioners into the mainstream.

The recurring theme of high out-of-pocket expenditure associated with private healthcare is discussed in more detail in the paper on healthcare financing, the sixth of the series. About 78% of total health expenditure in India is private, and two-thirds of this expenditure is associated with outpatient treatment. India has among the lowest public healthcare spending in the world, both as percentage of GDP (0.95% in 2005) and on per capita basis. The authors also note that in 2004-05, health spending was approximately 5.4% of total household consumption in rural areas (5.2% in urban areas) and only 10% of Indian households had medical insurance according to 2005-06 data. Households in rural and urban India respectively financed 47% and 31% of hospital admissions through borrowing and sale of assets in 2004. To improve healthcare financing in India, the authors suggest an eight-point approach including  reassessment of center-state partnership in NHRM, higher taxes to increase health spending to 3% of GDP in coming years, the introduction of health management information system to improve the performance of the providers, financial risk pooling, universal financial protection, enhanced regulation and oversight, and higher investment and improved returns to the same in the public healthcare sector.

The final paper of the series reviews the topics discussed by the previous authors, and calls for universal healthcare in India by year 2020. The authors propose the establishment of a national health system with the following main goals: “ensure the reach and quality of health services to all in India; reduce the financial burden of health care on individuals; and empower people to take care of their health and hold the health-care system accountable.” Specific targets and the means for their achievement are suggested in six key areas – integration of public and private service delivery, creation of a universal healthcare fund, improvement in human resources for health, use of an information system for health practices, rational use of drugs and technology, and decentralization of healthcare governance.

Image credit: Flickr: mallika.viegas

Health and Development